Panic Attack Management

1. Definition and Diagnosis

Panic disorder (not the same as a single panic attack) requires recurrent unexpected attacks plus either persistent concern about future attacks or maladaptive behavioral change related to them. It is a diagnosis of exclusion - medical causes must be ruled out first. - Rosen's Emergency Medicine, p. 2296

2. Rule Out Organic Causes First

• Cardiac: MI/angina (~25% of ED chest pain patients have panic disorder, but cardiac must be excluded first), arrhythmias, mitral valve prolapse
• Endocrine: hyperthyroidism/thyrotoxicosis, pheochromocytoma (check urinary catecholamines/plasma metanephrines), hypoparathyroidism, hypoglycemia
• Pulmonary: pulmonary embolism, asthma exacerbation, COPD
• Substance-related: cocaine, stimulant, cannabis intoxication; alcohol or benzodiazepine withdrawal
• Other psychiatric: OCD, PTSD, social phobia (panic attacks can occur as secondary features)

3. Acute Management (In the ED or Clinic)

Environmental Measures

• Place the patient in a quiet area, reduce stimuli (dim lights)
• Presence of a calm, supportive family member can help
• Reassurance and explanation that the symptoms are not life-threatening

Breathing Techniques

• Hyperventilation is a key driver - controlled, diaphragmatic breathing and paced breathing to correct respiratory alkalosis
• Patients with known hyperventilation syndrome benefit from reassurance and breathing therapy

Pharmacologic (Acute Episode)

• Rosen's Emergency Medicine, p. 2299

4. Long-Term / Outpatient Management

First-Line: SSRIs and SNRIs

• SSRIs (sertraline, paroxetine, escitalopram) and SNRIs are the first-line pharmacotherapy for panic disorder
• Broad spectrum of efficacy, high tolerability, low dependence risk
• Improvement typically seen in 4-6 weeks; doses may need adjustment
• Safer than older antidepressants and benzodiazepines for long-term use
• Most antidepressants are effective, with the probable exception of bupropion - Goldman-Cecil Medicine, p. 3762

First-Line Psychotherapy: Cognitive-Behavioral Therapy (CBT)

• Strong evidence from controlled trials for most anxiety disorders
• Behavioral component: uses learning theory to extinguish fear responses and reinforce functional behavior
• Cognitive component: identifies and corrects dysfunctional automatic thoughts that trigger the anxiety cascade
• Can be delivered individually, in group settings, or as family therapy
• For mild-moderate panic disorder: CBT may be used as sole therapy
• For severe or treatment-refractory cases: combine CBT with pharmacotherapy - Goldman-Cecil Medicine, p. 3762

Other Psychotherapies

• Panic-focused psychodynamic psychotherapy and applied relaxation training are alternatives with evidence of efficacy in panic disorder
• Exposure-based CBT (interoceptive exposure) is particularly effective - targeting the misinterpretation of body sensations

Other Pharmacologic Options

5. Comorbidity Considerations

• ~1/3 of panic disorder patients have comorbid agoraphobia - exposure-based CBT is especially important here
• High association with suicidal ideation (43%) and suicidal intent (55%) - thorough suicide risk assessment is mandatory in ED patients
• Panic disorder commonly comorbid with depression, substance use disorders, and other anxiety disorders
• Post-MI patients with comorbid anxiety have worse cardiac outcomes if anxiety is untreated

6. Management Summary

Acute attack:
  → Rule out life-threatening organic cause
  → Calm environment + reassurance
  → Controlled breathing
  → Benzodiazepine (short-term/PRN if needed)

Chronic/recurrent panic disorder:
  → First-line: SSRI or SNRI + CBT
  → Severe/refractory: combine pharmacotherapy + CBT
  → Monitor for agoraphobia, depression, suicidal ideation
  → Maintenance therapy often required (waxing-waning course)

Sources: Rosen's Emergency Medicine (p. 2296-2299); Goldman-Cecil Medicine (p. 3762); Goldman-Cecil Medicine Drug Table 362-9; Stahl's Essential Psychopharmacology